HLTCCD007 - Undertake moderately complex clinical coding
Overview
This unit describes the performance outcomes, skills and knowledge required to assign clinical classification codes to an admitted episode of care using patient and clinical data from moderately complex patient health care records.This unit applies to clinical coders who are responsible for interpreting and extracting patient clinical information for the purposes of clinical coding. Work may be performed as an individual or as part of a team under limited supervision.
Assessment
For Melbourne campuses
Assessment tasks will be designed to reinforce & extend knowledge and skill competence within set & controlled parameters in accordance with each units learning outcomes & performance criteria requirements, including the setting of work based practical application tasks designed to provide evidence of competence outcomes, within periodic and scheduled timelines.
Students will be expected to demonstrate the following required skills:
- use current coding manuals and standards to produce coded clinical data from moderately complex patient health care records for at least five episodes - of care for each of the following:
- infectious and parasitic diseases
- neoplasms
- diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
- endocrine, nutritional and metabolic diseases
- mental and behavioural disorders
- diseases of the nervous system
- diseases of the eye and adnexa
- diseases of the ear and mastoid process
- diseases of the circulatory system
- diseases of the respiratory system
- diseases of the digestive system
- diseases of the skin and subcutaneous tissue
- diseases of the musculoskeletal system and connective tissue
- diseases of the genitourinary system
- pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
- symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified
- injury, poisoning and causes of morbidity and mortality
- for each of the above, record, edit, amend and maintain validity of coded clinical data according to current classification standards and conventions
- for the above, episodes of care should collectively include the following:
- differing lengths of stay
- both acute and chronic forms of a disease or condition
- different care types
- with disease or condition in different contexts including co-existing with multiple comorbidities and complications
- participate in at least one coding audit of own work and:
- identify type of coding audit and its purpose and prepare relevant patient health care records
- respond to coding audit findings addressing any discrepancies.
- meet organisational requirements for coding performance including not exceeding acceptable percentage error rate.
Required reading
The qualified trainer and assessor will provide teaching and learning materials as required in the form of workbooks produced by the VU Polytechnic and/or via the VU Polytechnic e-learning system.
As part of a course
This unit is studied as part of the following course(s):